Glaucoma is a chronic, progressive, blinding disease that impacts more than 4 million people in the United States.¹ As ophthalmologists, we regularly detect previously undiagnosed glaucoma in patients. For a long time, topical IOP-lowering agents were the mainstay of glaucoma treatment. While these can be highly effective, poor patient compliance makes them a less-than-ideal first-line therapy.

Many factors play a role in suboptimal medication adherence, including poor patient understanding of the disease process, difficulty administering or remembering the drops, poor tolerance of the medication, and significant ongoing cost.² Patients have no subjective perception of treatment efficacy, making compliance more difficult, and studies have shown that younger patients with mild to moderate glaucoma are less likely to properly follow treatment plans compared to older patients with more severe disease.³

We are fortunate to have a multitude of interventional treatment options that work particularly well in the early stages of disease. These include selective laser trabeculoplasty (SLT) as well as sustained drug-delivery devices, such as Durysta (Allergan) and iDose TR (Glaukos). Patients frequently ask me, “What would you do if this was your eye?” My answer to them is simple: I would want the most effective option that requires the least amount of effort.

As a subspecialty, glaucoma specialists are now transitioning to an interventional approach in managing the disease. A key component of “interventional glaucoma” is putting the patient’s treatment back into the physician’s hands. For a long time, we have depended on the patient to treat their glaucoma with drops, which has been an imperfect process due to all the reasons mentioned above. We now can regain that control by treating the patient with low-risk, minimally-invasive, in-office procedures that have changed the treatment paradigm along with our patients’ lives.

An SLT Resurgence

SLT was originally approved by the FDA as a procedure separate from argon laser trabeculoplasty (ALT) in 2002.⁴ However, the procedure has undergone a resurgence among clinicians since the landmark Laser in Glaucoma and Ocular Hypertension (LiGHT) trial was published in 2019.

The LiGHT trial was a large, randomized, controlled trial of treatment- naïve patients with ocular hypertension or primary open-angle glaucoma that compared the efficacy of SLT to eye drops through 3 years of follow-up. The investigators found that most eyes (74.2%) treated with SLT required no additional eye drops to maintain their target IOP and were within their target IOP at 93% of visits. Rates of progression and the need for glaucoma surgery were lower in the SLT group, which suggested that SLT resulted in better clinical outcomes and better stability of the patient’s disease. Furthermore, SLT may provide improved control of diurnal variation of IOP.

Notably, SLT decreases the patient’s dependence on glaucoma drops, thus decreasing the need for compliance, the incidence of side effects, and the cost.⁵ This means that, along with improved disease control, SLT also leads to an improvement in the patient’s quality of life.

Easing Clinic Flow

Bringing a new technology to a busy, fast-paced clinic can be daunting. Many physicians feel uncomfortable discussing a procedure with patients they have just met, preferring to start with a conservative therapy like eye drops. Others avoid talking about SLT because they are under time constraints and worry about how adding the procedure will impact clinic flow. However, while it may be intimidating to discuss SLT with a newly diagnosed patient, it’s important to remember that these patients probably aren’t considering the difficulties of administering drops every day for the rest of their lives, much less the associated cost and potential side effects of those drops.

Although fitting in a conversation about SLT and performing the procedure itself may initially seem to slow clinic flow, one should factor in the amount of time that SLT will ultimately save downstream. Fewer patients using drops means far fewer phone calls about medication for staff to field with pharmacies, insurance companies and patients themselves.

Plus, with less emphasis on compliance, patient visits also become easier. There is a decreased need to talk about tolerance and an increased comfort in knowing that SLT is continuously influencing the patient’s IOP. Also, new technological advances like direct SLT (Alcon) allow physicians to perform the entire procedure within a few seconds and without a contact gonioscopy lens, further increasing efficiency.

It is also important to set up a clinic flow that works for you. In my clinic, that means dedicating one day per week to only lasers and postoperative patients. The laser is stationed in proximity to my exam lanes, so I can easily perform a procedure while my next patient is being roomed for examination. My technicians prepare and consent the patient for laser and immediately bring them to the laser room. After the treatment is completed, the technician answers any patient questions and reviews post-procedure instructions.

This has proven to be an efficient way to perform multiple laser procedures while seeing patients at the same time. I only offer same-day laser treatment if the patient has traveled a significant distance or has great difficulty returning to the clinic. This way, insurance coverage and prior authorization can be obtained and verified, and there is less disruption to the flow of a busy clinic day.

Remember that you may need to add the -25 modifier on your exam code if performing a same-day SLT, and be mindful of individual payer policies regarding modifier usage and prior authorization requirements that can vary significantly by geography.

Allaying Patients’ Fears

Presenting the option of laser trabeculoplasty with a careful discussion can reassure the patient about their treatment choice. With new patients, I typically don’t discuss drops; I go straight to interventional methods of treating glaucoma, including SLT. I review the data showing that laser trabeculoplasty is more effective than topical IOP-lowering agents while also requiring less work on their behalf. I always mention that if this were my eye, I would choose SLT. However, patients are often alarmed at hearing the word “laser” in the context of their eye. It is important to allay these fears, so I typically describe the procedure as a two-minute, painless treatment in the office that requires minimal to no postoperative care. It is important to mention that the procedure may not work in everyone, though most patients experience an IOP-lowering effect.

Patients should also understand that the procedure is repeatable should the effect start to wane, and that undergoing SLT—even more than once—does not preclude the eye from receiving any further treatment in the future. They should know of the overarching benefits: decreased dependence on drops, decreased medication-related cost and decreased medication intolerances. After reviewing these points, many patients are happy to reduce their existing medication burden or to avoid starting an additional medication, and they find SLT to be a very appealing option.

Bringing in new technology to the clinic can be stressful, but preparing yourself with the proper tools can help you manage your patients’ glaucoma in a manner that improves both the lifestyle of the patient and the clinic flow for the physician, while optimizing disease control. OM

References 

1. Ehrlich JR, Burke-Conte Z, Wittenborn JS, et al. Prevalence of glaucoma among US adults in 2022. JAMA Ophthalmol. 2024;142(11):1046–1053. doi:10.1001/jamaophthalmol.2024.3884

2. Zaharia AC, Dumitrescu OM, Radu M, Rogoz RE. Adherence to therapy in glaucoma treatment—a review. J Pers Med. 2022 Mar 22;12(4):514. doi: 10.3390/jpm12040514. PMID: 35455630; PMCID: PMC9032050.

3. Sleath BL, Blalock SJ, Muir KW, et al. Determinants of self-reported barriers to glaucoma medicine administration and adherence: a multisite study. Ann Pharmacother. 2014;48(7):856-862. doi:10.1177/1060028014529413

4. Jha B, Bhartiya S, Sharma R, Arora T, Dada T. Selective Laser Trabeculoplasty: An Overview. J Curr Glaucoma Pract. 2012 May-Aug;6(2):79-90. doi: 10.5005/jp-journals-10008-1111. Epub 2012 Aug 16. PMID: 28028351; PMCID: PMC5161772.

5. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al.; LiGHT Trial Study Group. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019 Apr 13;393(10180):1505-1516. doi: 10.1016/S0140-6736(18)32213-X. Epub 2019 Mar 9. Erratum in: Lancet. 2019 Jul 6;394(10192):e1. doi: 10.1016/S0140-6736(19)31503-X. PMID: 30862377; PMCID: PMC6495367.

Shivani S. Kamat, MD is an associate professor of ophthalmology at the University of Texas Southwestern Medical Center in Dallas, where she leads the glaucoma service and is the glaucoma fellowship director.